Regional Director Quality and Reliability

The information described in this job description has been designed to indicate the general nature of the work performed. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this job.

Other information:

Job Summary
The Regional Director of Quality and Reliability is responsible for developing and executing organizational quality and the delivery of highly reliable care. This individual is a consummate advocate and leader, ensuring organizational wide adherence to a continuously improving culture of safety, in addition to enterprise-wide compliance with regulatory and accreditation requirements.

Essential Functions
Provide leadership to the Quality Assurance and Performance Improvement teams including the development and management of the budget for the department
Provide consultation and skill development in quality improvement activities to operational and clinical leaders and staff
Partner with service line leaders in the utilization of data to effectively impact clinical improvement and in the creation of departmental quality plans
Operational leader of organizational wide high reliability transformation, including standardized approach to improvement methodology
Facilitates the development of the Quality Management strategy and goals throughout the organization
Work collaboratively with the CQO to prioritize and execute the quality management strategy and annual goals
Oversight of clinical audits and corrective action plan for effectiveness, escalating appropriately areas of opportunity through the quality management system structure
Operational oversight of regulatory and accreditation survey readiness throughout the organization
Regularly measure and report the manner and degree to which the organization is regulatory compliant through audits, surveys and other assessments as needed to ascertain and quantify regulatory compliance
Meet all regulatory reporting requirements and timelines with accurate information, including but not limited to reporting to DOH, WHSA and CMS as well as oversight of Corrective Action Plans
Assist in maintaining and continuously improving the quality committee structure for the organization
Maintenance and standardization of policies and procedures
Ensure quality programs throughout the organization meet guidelines and requirements consistent with SRH’s strategic plan and SRH’s Quality Management System
Oversee and chair the Regional Quality Oversight Committee
Lead cause analysis investigations and oversee resulting corrective action plans
Ensure systems are in place to report clinical data elements accurately and timely through the quality management system and to required regulatory bodies and quality partners
Ensure contracts contain relevant quality standards, track quality outcomes of contracts, and oversee corrective action when quality outcome are not in compliance with contracts
Oversee and ensure enterprise-wide compliance with the International Organization for Standardization’s Quality Management Standards, ISO 9000
Maintain ability to effectively utilize Microsoft Office (Outlook) and department specific software applications to perform work
Communicate effectively and cooperatively in the workplace
Comply with all Skagit Regional Health, department and location specific policies and procedures

Education
Master’s Degree in Nursing, Health administration or Business Administration required.

Experience/Training
Minimum seven (7) years of experience in healthcare leadership

License/Certifications
Certified Professional in Healthcare Quality (CPHQ) within one year of start date required. Current Washington State RN Licensure required.

Other Skills
Required:

• Significant knowledge of state and federal regulatory standards for health care
• Hands-on experience in quality improvement and process improvement with ability to describe robust past achievements
• Experience with integrated healthcare delivery systems
• Demonstrated experience with data management and a facility with statistical analysis and data collection toolsAbility to work independently and with small and large groups of healthcare professionals, providers and others in the organization to problem-solve, set priorities, and communicate effectively in both oral and written form. Lean, Six Sigma or other process improvement experience

Preferred:

• Experience with Det Norske Veritas (DNV) accreditation and International Organization for Standardization’s Quality Management Standards (ISO 9000)

Physical Demands and Work Environment
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for long periods of time; when working in office. Repetitive tasks such as typing, sitting, answering phones, and interacting with computers and computer systems most of the day is a function of the position. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to focus. This position requires working in an indoor, environmentally controlled environment when in the office.

Skagit Regional Health offers a comprehensive benefit package including medical, dental, vision, 457b/401a (retirement), long term disability, and paid time off to all employees holding an FTE of 20 or more hours per week. Eligible employees also receive sick time pay.